Understanding and Interpreting an FCE

An FCE needs to be objective, non biased, evidence based in order to be fair to the injured worker and referral source.

The goal is to obtain a “valid” FCE

Other Common Test Names • Work Tolerance Screening (WTS) • Functional Abilities Evaluation (FAE) • Functional Capacity Assessment (FCA) • Work Capacity Evaluation (WCE)

FCE Purpose- Provides objective data to assess Capabilities and Limitations • The report needs to answer the referral question???? • Is the patient giving effort that is maximum or near maximum effort in order to accurately determine: • • • •

Work Status Work Placement Settlement Determine next course of action • Surgery • Other medical interventions • Missed diagnosis

A Physican should avoid placing arbitrary restrictions on abilities without objective assessment and measurement

FCE • Assesses • Validity/Reliability • Consistency of Effort • Quality of effort PROBLEM: What do we do when the patient does not give “good” objective effort

Who Should Perform an FCE? • May be dependent on state practice act guidelines • Needs to be a provider who has the clinical expertise and can legally provide a clinical opinion • Analyze, interpret and conclude by answering referral question • Provider needs to be objective/non biased-Should not be “treating” clinician • Provider needs to have knowledge to consider all components (medical history, current medical condition, etc)

Who Should Perform an FCE? Occupational Therapist

The FCE needs to be defensible in court

Check the signature line

Indicators for FCE Medical • Job involves repetitive work task • Job involves Medium to Heavy work • Complaints of pain with no substantiated clinical findings • Plateau in PT/OT • MedicaI(MMI) • Decreased work tolerance

Behavioral Legal • Off from work 3 months • Objective or more documentation • Loss of past work needed to habits and selfreturn to work confidence • Return to work • Fear of re-injury will require job • Negative attitude about modification returning to work • Conflict of • Questionable legitimacy medical opinion of injury about worker’s • Suspected substatus maximal effort • Lack of progress in physical/occupational therapy without clear objective reasoning • Lack of participation in therapy

Patients referred for FCE & WCE need to medically stable: • Resting HR greater than 100 bpm • Blood pressure not greater than 160/100 • Pain has stabilized

Stages of High Blood Pressure in Adults

• Able to tolerate activity-2 hours

• Soft tissue healing will not jeopardized with maximum tolerance testing Stages Prehypertension High Blood Pressure Stage 1 High Blood Pressure Stage 2

Systolic 120-139 140-159 160 or higher

And/OR OR Or Or

Diastolic 80-89 90-99 100 or higher

11

FCE Approaches • Psychophysical Approach: Subjective complaints determine progression of tolerance testing. It is not based on the presence or absence of mechanical changes or deficits witnessed. Client is in charge of the testing process. • Kinesiophysical Approach: Athletico (previously Accelerated) Mechanical changes or deficits need to correlate with the subjective pain complaints.

Kinesiophysical Approach cont’d. • Evaluator Determines stopping point • Based on the observation of mechanical changes which should be observed when max effort is given. • Based on our medical knowledge of biomechanics, diagnosis, physiology, anatomy, & cardiovascular endurance • If Client terminates task before a mechanical change is noted and or kinesiophysical signs are observed, , it can be assumed that maximum effort was not given on that specific task.

Different Types of FCE’s (should be part of the referral question)

• Baseline FCE

• Assessment of the functional ability to perform the spectrum of work tolerances related to the physical demand factors of job tasks • Best suited when restricted duty is available or RTW to previous job is highly improbable • MMI, disability, vocational re-training/assessment

• Job-specific FCE • Assessment of the match between the client’s functional capabilities and the critical demands of a specific job • Answers the referral question - “Can the client return to work to the previous job?” • Accomplished by evaluating work tolerances with specific parameters and the use of structured work simulations

Different Types of FCE’s Cont. • UE FCE • Initiated with M-S Eval • Assessment of only the physical capabilities and tolerances that incorporate UE usage • Will not evaluate sitting, standing, stoop, squat, kneel, crouch, etc. • The referral source should speak to the therapist upon making the referral so the evaluation is scheduled with the most appropriate therapist.

16

17

18

Value of Providing Job Description for JobSpecific FCE

• Provides accurate parameters for RTW • Ensures that client will only be assessed on tolerances specific to job • Ensures that the evaluator will be able to establish recommendations, which are appropriate and reasonable for the job/employer

Name: _____________________Signature__________________Job Title________________________ Employer __________________Do you have a case manager? _________If Yes, Please provide contact information:___________________________________________________________________________ LIFTING: What is the heaviest item you typically lift at work from floor to waist level? _____________________ How much does it weigh?______________ How often do you lift this item/object? (Please check box) 1-100 times/day (12/hr)

1 101-500 times/day (12-62 lifts/hr)

Greater than500/day (over 62/hr)

•Accurate job description is critical

Are there items you lift which are lighter than above that you lift more frequently to waist level? How much does it weigh?______________ How often do you lift this item/object? (Please check box) 1-100 times/day (12/hr)

1 101-500 times/day (12-62 lifts/hr)

Greater than500/day (over 62/hr)

What is the heaviest item you typically lift at work to shoulder level? __________________________ How much does it weigh?______________ How often do you lift this item/object? (Please check box) 1-100 times/day (12/hr)

1 101-500 times/day (12-62 lifts/hr)

Greater than500/day (over 62/hr)

What is the heaviest item you typically lift to overhead level? ________________________________ How much does it weigh? _____________ How often do you lift this item/object? (Please check box) 1-100 times/day (12/hr)

1 101-500 times/day (12-62 lifts/hr)

Greater than500/day (over 62/hr)

CARRYING: Do you carry items with two hands? Yes_____ No _______ Describe Item ____________________ How much do the items weigh? ______________ How far do you carry the item? _________feet How often do you carry the items? (Please check box) 1-100 times/day (12/hr) 1 101-500 times/day (12-62 lifts/hr)

Greater than500/day (over 62/hr)

Do you carry items with one hand? Yes_____ No _______ Describe Item ____________________ How much do the items weigh? ______________ How far do you carry the item?_________feet How often do you carry the items? (please check box 1-100 times/day (12/hr)

1 101-500 times/day (12-62 lifts/hr)

Greater than500/day (over 62/hr)

PUSH/PULL: Do you push or pull items at work? ________ If yes, do you use a cart to push or pull items?______

•Goal: request a functional job description with job demands at time of initial evaluation •If no job description is available, therapist receives job information from the Injured Worker

If you use a cart, describe how much weight is on the cart? _________________________________ Please check the boxes below if you have to get in the positions while at work

Squat Kneel Crawl Run Climb Stairs Climb Ladders Above Shoulder Reaching Below Shoulder Reaching

0% Never

1-33% of the work day

34-66% Of the work day

67-100% of the work day

Occasional

Frequent

continuous

•Athletico can send a copy of this form to the employer

Need to know if patient can do this task when they return? --Job SpecificNeed Job Description

21

Evaluation ProcessHow long does it take? What is assessed? • 4-6 hours in duration • Review medical record—Important to get accurate description of injury and review medical records—(Previous therapy, surgeries, history, etc)

• Pain and activity/disability questionnaires • Gain insight to why observed limitations may be disporportionate to objective finding. • Musculoskeletal evaluation • Non material handling assessment-repeated movements • Objective Functional testing-lifting/carrying/job sim • Repeat testing of 1 & 2 hand lifting performance-throughout FCE –confirms abilities • Job Simulation Tasks or Functional Circuit-confirms ability previously assessed during the FCE

Why is a M-S Evaluation important as part of an FCE • Should be part of all FCEs- Check with your provider • Determines whether client meets admission criteria • MS evaluation allows Evaluator to distinguish between limitations in performance due to impairment or lack of effort without any MS findings to support the observation –Is there a correlation? • Evaluator may not know why (fear, anxiety) • Ex: Knee diagnosis: may have difficulty getting into a full squat due to limitations in ROM. (FCE evaluator would not know this if they did not measure it during a MS evaluation • Assists in predicting functional performance • Client may need “good” PT before proceeding

Evaluation: Physical Tolerance Testing• Floor to Waist • 12” to Waist • Waist to Shoulder • Shoulder to Overhead

• Non material handling Activities • Sitting, standing, reaching, kneeling, squatting, bending, ladder, stairs,

• Balance Assessment • Static and Dynamic

Job Simulation Tasks/Functional Activity Circuits

• Performed to assess tolerance to perform tasks outside of standard lifting parameters • Job Specific

• Functional Activity Circuit • Usually 30-60 minutes • Verifies weights observed during formal tolerance testing, assesses endurance, allows evaluator to make recommendations for work tolerances.

How do you know if the client is exerting a “good effort” which is representative of their abilities? • Skill of evaluator-ask !!!!! • Battery of tests • Observation throughout FCE ▫ Walking into the facility ▫ Sitting tolerance while filling out paperwork

• Pain and Activity Questionnaires • Assess clients perception of their pain and disability

Objective testing •Musculoskeletal exam •Function testing •Circuit/Cross Reference lifting •The greater the number of battery of tests, the more likelihood to observe consistent behaviors.

27

Critical FCE Metrics-Every FCE methodology has internal rating system- No standard Metrics: • Consistency of Effort • Reliability of Pain /Performance • Quality of Effort

Most Common

Athletico has 3 areas of objective measurement that is gathered during the assessment. Many testing methodologies combine it into 2

3 Effort Metrics Definitions • Consistency of Effort = Reproducibility - or the likelihood that an effort may be copied, duplicated, or produced as a close imitation, in a series of trials. • Quality of Effort = Degree - or the extent, level, or scope of a subject's volitional exertion in maximal or repetitive testing. • Reliability of Pain-Non-Organic Signs = descriptions or expressions of pain or symptomatology that do not subscribe to the scientific laws of living organisms

How is Maximum Effort Determined? • Research is conflicting • The more measures in an FCE and the experience of the evaluator promotes a more accurate result • Cross reference tasks, gross inconsistencies, • Multiple methods during testing

• Goal: Objective FCE designed to assess true physical capabilities based on the performance of good and or maximum effort • Requires a thorough knowledge of what is expected for the condition in question and the capacity to observe or elicit what is expected and what is not.

Reliability Reliability of Pain-Approx 72 criteria if everything is tested (Athletico) • Pain & Activity Questionnaires • Observational Findings • ROM in MS eval compared to ROM when not directly tested • Mechanical Changes associated with Functional Pain Increase • RPE vs HR Comparison

Examples Is claimant always having difficulty assuming positions of squatting If limp is consistent throughout the exam Cross referencing maximum lifting (2 hand lift) Perception of pain/abilities consistent with performance

Consistency of Effort • Important to have a battery of objective tests-dispersed throughout FCE • Research-based tests that can withstand a legal challenge • Fewer tests contribute to the propensity for inappropriate interpretation • Consistency of Effort-38 criteria if everything is tested (Athletico) • Manual Material handling sequencing-Ex: Occ > Freq • CoVs - Spinal Inclinometer, Jamar, & Static Strength testing, pinch • Bell Shaped Curve – Jamar, Rapid Grip • Repeated movements: overhead reach, squatting, bending • Should observe same behaviors and limitations throughout the test.

Example of inconsistent observation

Consistent ROM noted with different tasks==consistent performance

34

Quality of Effort • Quality of Effort--74 criteria if everything is tested (Athletico) • 2-3 Kinesiophysical Signs noted which demonstrates good effort-evidence based • Heart Rate Variance >25% from Resting Heart Rate • Self terminated without clinical objective findings-if client did not attempt, refused, or stopped before any mechanical change noted— Not a quality effort

Kinesiophysical Signs - Quality of Effort • Muscle Recruitment • Body Mechanics • Base of Support • Counterbalance • Control & Safety • Heart Rate

Expected & Unexpected Results Every activity that is performed in an FCE should be evaluated against a metric. --FCEs should be objective and non biased. • Expected results = • What the therapist should see if the patient is giving good effort and there are objective findings to substantiate pain ratings or there are objective findings to substantiate acceptable, observed quality of effort • Unexpected Results = • When Client is not giving full effort • there are no kinesiophysical signs or Mechanical Changes • Terminates activity without increase in pain or objective findings • Response does not correlate to diagnosis

•Every activity in an FCE has a purpose. •Overall results/Performance is analyzed to determine an overall “rating” that classifies performance •Important to have many tests and not base results on one parameter

Results:FCE Performance Overall Rating-based on Combined Total Effort Every system has their own internal grading system. What is most important is that testing methodology is consistent and principles are build on evidence based research. • 80--100% = Consistent Performance/Acceptable Effort • 70-79.99% = Variable Performance /Questionable Effort • 0--69.99% = Inconsistent Performance /Unacceptable Effort

Performance Criteria Definitions • 80-100% - Consistent Performance/Acceptable Effort indicates that the client’s perceived limitations, and return to work confidence are not negatively affecting symptom expression, consistency of effort, reliability of pain, and/or quality of effort. Data obtained is near or equal to the Client’s true status. The evaluator is confident in projecting full time work tolerances.

Most Difficult –What do we do? • 70% - 79.99% Variable Performance / Questionable Effort • Variable Performance /Questionable effort indicates that the client’s perceived limitations and return to work confidence are mildly to moderately affecting symptom expression, consistency of effort, reliability of pain, and/or quality of effort. The client likely could have performed at higher levels than willing during musculoskeletal and functional testing. The client can perform on a full time basis at least at levels identified in this report.

• 0--69.99% Inconsistent Performance / Unacceptable Effort • Inconsistent Performance/Unacceptable Effort indicates the Client’s perceived limitations and return to work confidence are markedly affecting symptom expression, consistency of effort, reliability of pain, and quality of effort. The client could have performed at markedly higher levels than willing during musculoskeletal and functional testing. Behavioral factors are affecting evaluation results to such a degree the evaluator cannot identify the client’s true musculoskeletal status, project full-time work tasks and/or true impairment. The physician will determine final disposition after review of this report and other relevant medical findings.

So Now What? Reader has to be able to interpret the report Interpret information, Overall Performance What are the recommendations? Was referral question answered?

What is important: Can the end user interpret the report?

Report needs to be end user friendly--communicate information easily

Determining Physical Demand Level: PHYSICAL DEMAND LEVEL

OCCASIONAL

FREQUENT

CONSTANT

0-33% OF WORKDAY 0-2.5/hrs/day

34-66% OF WORKDAY 2.5-5.5 hrs/day

67-100% OF THE WORKDAY Greater than 5.5 hrs/day

0-100 Reps/day Up to 12.5/lifts/hour 1 lift every 5 min

101-499 Reps/day 12-62 lifts/hour 1 lift every 5 min to 1 lift every min

500+ Reps/Day Greater than 62 lifts/Hour 1 lift/min or greater

SEDENTARY

10 LBS OR LESS

Negligible

LIGHT

20 LBS

MEDIUM

20-50 LBS

WALKING/CARRYING

TYPICAL ENERGY REQUIRED

Negligible

Negligible

1.5-2.1 METS

10 Lbs. and /or walk/stand/push/ pull of arm/leg Controls

Negligible and/or push/pull of arm/leg controls while seated

2.5 MPH. NO GRADE OR SLOWER SPEES WITH 10 LBS OR LESS

10-25 LBS

10 LBS

2.5-3.5 MPH. NO GRADE OR SLOWER SPEED WITH 25 LBS OR LESS

2.2-3.5 METS

3.6-6.3 METS

HEAVY

50-100 LBS

25-50 LBS

10-20 LBS

3.5 MPH WITH 50 LBS OR LESS LOAD

6.4-7.5 METS

VERY HEAVY

IN EXCESS OF 100 LBS

Over 50 LBS

Over 20 LBS

3.5 MPH WITH 50 LBS OR MORE LOAD

Over 7.5 METS and up to 12 METS

1993 Leonard N. Matheson, PHD Department of Labor Combination from Accelerated /AthleticoClinical Experience, Worksteps, DOL,

Value of Results Decision Making Process Maximum effort: Consistent, Reliable performance

• Can accurately define functional performance levelPDL • Determine if further care is appropriate as identified in the musculoskeletal exam

Not consistent in effort and reliability is in question/invalid • Objective findings do not correlate with subjective complaints

• Physician to determine medical course of action

• Misdiagnosed?

• Accurate physical demand level is unable to be obtained due to lack of maximum effort.

• Triage to work conditioning

• PDL level unable to be determined

• Job coaching to return to work

• Inform the claimant

• On site job analysis

• IME

• RTW –

• Return to Work

• Case closure

• Case Closure

Common Questions from Customers • Can you put my client in a work

• Do I need an FCE? • Need an FCE to determine current level of function • FCE will help determine appropriate course of treatment • Identify if patient is reliable/consistent ▫ Work conditioning ▫ Return to work ▫ Job consultation ▫ Job coaching

conditioning program without doing an FCE? YES

▫ Goal is to promote success and compliance ▫ Patient is learning how to transition from PT to work conditioning ▫ Evaluation should be a submax level to determine safe/acceptable starting point in Work Conditioning ▫ Start in program-provide supervision, proper progression and goal planning and defining expectations.

Common Questions from Customers Can you put my client in a work conditioning program if the FCE results showed inconsistent/invalid results?

May do a 1 week trial to see if behavior changes May do 1 week if physician or insurance company needs to gather more objective information on behavior patterns.

Common Questions from Customers • Do I need an FCE after a Work Conditioning Program? ▫ Not if the work conditioning program is comprehensive and provides a discharge report that reports abilities compared to job requirements. ▫ Why assess effort if client was successful in a program and has met job demands within a program.

Why do therapy companies request medical records? Value of forwarding medical diagnostics and or medical records to evaluating therapist--

• Ensures accuracy of informative vs. client self-report • Provides timeline sequences of medical involvement • R/O’s need for additional medical and therapeutic intervention—avoids inappropriate recommendations

54